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I 9. V.!pf COUNTY OF SAN JOAQUIN ,...c. <br />..c. ?. • -.0 OFFICE OF EMERGENCY SERVICES \ \ (C. t- ' CEA/ED r.: •,-, .1. 2101 E. Earhart Avenue, Suite 300 <br />A pi i-; ..< Stockton, California 95206 MAR 29 2011 .-iti p. Telephone: (209) 953-6200 <br />Fax: (209) 953-6268 SAN joA ri ki'giiIii OFFCE OF WON CCU HAZARDOUS MATERIALS PROGRAM INSPECTION FORM E ar.L"Li. <br />BUSINESS NAME ADDRESS (Facility Being Inspected) el/ KCEs <br />U — ,,, <br />\, <br />\ CCOUNT # <br />; (-7 <br />jSTART DATE (New Bus) INSI'l CI ID \ DATE ARRIVAL TIME DEPARTURE TIME INSBEICTOR NAME <br />INSPECTION RESULTS <br />DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br />I. HMMP/Map On Hand and Easily Accessible ..-). Facility Map Complete and Accurate <br />2. Business Identification Page Complete & Accurate 6 Employees Familiar with HMMP <br />3. Business HMMP Complete and Accurate 7. Training Records Available <br />4. Chemical Description Pages Complete and Accurate 8. Unsafe Conditions Observed (see details below) <br />EXPLANATION OF FINDINGS AND COMMENTS <br />-1 <br />INSPECTION FOLLOW UP INFORNIATION <br />Corrective Actions - , <br />To Be Submitted By: i ___. ,.-:' / i Additional <br />Referrals/Notes: <br />1CKNOWLEDGENIENT OF REVIEW .AND RECEIPT OF INSPECTION RESULTS <br />Business Representative( Print Name and Title)Business <br />e i , , <br />Representative (Signature) <br />WHITE COPY <br />PINK COPY: